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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191226432
Report Date: 08/05/2024
Date Signed: 08/05/2024 10:32:31 AM

Document Has Been Signed on 08/05/2024 10:32 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:SUSANNA WESLEY CHILDREN'S CTR/INFANTFACILITY NUMBER:
191226432
ADMINISTRATOR/
DIRECTOR:		RENEE SPIVEYFACILITY TYPE:
830
ADDRESS:134 N. KENWOOD ST.TELEPHONE:
(818) 548-6229
CITY:GLENDALESTATE: CAZIP CODE:
91206
CAPACITY: 19TOTAL ENROLLED CHILDREN: 19CENSUS: 3DATE:
08/05/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Renee Spivey, Director TIME VISIT/
INSPECTION COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA), Anomeh Eivazian, conducted an unannounced case- management inspection to the above facility on 08/05/24 at 10:00 am. LPA met with Renee Spivey, Director who guided LPA on a tour of the facility. During this inspection there were total of 3 infants present in the facility with 3 staff.

Based on staff#1 interview that was conducted on 07/15/24, on 06/10/24 child#1’s parent observed child#1’s Epi-Pen was stored in the infant classroom refrigerator. Parent#1, took child#1’s Epi-Pen out from refrigerator and provided the school with a new Epi-Pen next day. Epi-Pen can not be stored in the refrigerator. Based on child#1 file, child was attending this program since 02/14/23.



The following deficiencies listed on the attached LIC 809 (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

LPA Eivazian informed director, Renee Spivey that this report dated 08/05/24 document(s) (1 Type A citation). Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Eivazian informed the director, Renee Spivey to provide a copy of this licensing report dated 08/05/24 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

The Notice of Site Visit (LIC 9213) was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted and report was reviewed with the Renee Spivey, director.

SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/05/2024 10:32 AM - It Cannot Be Edited


Created By: Anomeh Eivazian On 08/05/2024 at 08:53 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: SUSANNA WESLEY CHILDREN'S CTR/INFANT
FACILITY NUMBER: 191226432

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/05/2024
Section Cited
CCR
101226(e)(1)(A)

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101226(e )(1)(A)-- Health-Related Services
(A) Medications shall be kept in a safe place inaccessible to children.

This requirement was not met as evidenced by...
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Per staff#1, child#1's parent brought a new Epi-Pen next day on 06/11/24 and all staff were trained about how to store medication. Also, a new medical log and folder was made for each classroom.
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Based on staff#1 interview on 07/15/24, on 06/10/24 child#1’s parent observed child#1’s Epi-Pen was stored in the infant classroom refrigerator. Epi-Pen can not be stored in the refrigerator.
This poses an immediate health, safety, and personal right risk to the children in care.
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A written declaration will be submitted to LPA by 08/06/24.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Christina Gabelman
LICENSING EVALUATOR NAME:Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2024


LIC809 (FAS) - (06/04)
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